PATIENT-CENTERED MEDICAL HOMES AND HEALTH CARE REFORM
By: John Kasprak, Senior Attorney
The patient-centered medical home (PCMH) model is based on the concept that a strong primary care system can improve health care quality. Greater access to primary care can also lower costs. The PCMH model seeks to improve care coordination, increase the value of health care services provided, expand administrative and quality innovations, promote active patient and family involvement in health care, and help control health care costs. Effective transformation to this model requires investment in health information technology, reform of current payment systems, and other changes to the current methods of delivering care. Both the state and federal government recognize the significance of PCMHs in health care reform efforts.
What are Patient-Centered Medical Homes?
The PCMH is a model of delivering health care designed and centered on the patient's needs. This model seeks to strengthen the provider -patient relationship by replacing episodic care based on illnesses and patient complaints with coordinated care and a long-term healing relationship. In a PCMH, the primary care provider leads a team of medical specialists, nurses, other providers, and the patient and his or her family in coordinating care for all of the patient's health needs.
The American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Osteopathic Association have jointly defined the medical home as a model of care where each patient has an ongoing relationship with a personal physician who leads a team that takes collective responsibility for patient care.
What are Key Elements of the PCMH?
Two key elements of the PCMH are health information technology (HIT) and payment reform.
HIT. HIT can promote the coordination of care and the implementation of the medical home model of care. Generally, HIT can help to improve communication among the medical home team, increasing the quality of the patient's care. For example, the use of electronic health records (EHRs), computer-based systems that record patient information including health and treatment histories, is an important element for the success of the PCMH. Health information exchanges (HIEs), internet portals that allow health care providers to transmit information to other providers involved in a patient care, are another key element.
Payment Reform. In the PCMH model, the traditional fee-for-service payment system would need to be adjusted to account for additional work that the physician and other providers perform in order to coordinate the patient's care. Payment reforms would provide more support for services that tend to be inadequately reimbursed in the fee-for-service system including patient education and training to improve self-management of disease, communications with other providers to coordinate patient care, and, interactions with patients outside the clinical setting.
What are the Benefits of the PCMH?
A PCMH offers potential benefits to patients, providers, and insurers. Patients receive more personal, higher quality coordinated care. Providers can take a more comprehensive approach to managing their patients' care. For insurers, whether private health plans or government programs, the PCMH model offers potentially significant cost savings as duplication and inefficiency are eliminated, as well as avoidance of hospital visits.
What are the Concerns about the PCMH?
PCMH development is closely tied to payment reform. For the model to work, providers must receive adequate compensation for the additional time and effort involved in coordinating care among multiple sites and providers. Primary care practices in Connecticut, as in other states, are financially fragile and may not be in a position to invest in the transformation to a PCMH without assistance with initial costs such as those involving HIT.
Another concern involves the adequacy of the health care workforce, particularly the shortage of primary care providers.
Are PCMHs Formally Recognized by any National Organization?
The National Committee for Quality Assurance (NCQA), a not-for-profit organization that has developed quality standards and performance measures for various health care entities and providers, has the only standardized, nationally - recognized PCMH recognition program. In 2008, NCQA released standards for “Physician Practice Connections-Patient Centered Medical Homes (PCC-PCMH) to identify primary care practices that function as PCMHs. Among the aspects of care measured by PPC-PCMH are access and communication, patient tracking and registry functions, care management, patient self-management support, electronic prescribing, test tracking, referral tracking, performance reporting and improvement, and advanced electronic communication.
NCQA recognizes three levels of PCMHs. This recognition, which demonstrates that a physician practice is a PCMH, can be significant as many private and public health plans and employers are considering projects to recognize and compensate practices as PCMHs.
There are no recognized NCQA PCMHs in Connecticut. But the state does have two PCMH initiatives (see next section).
For more information on the NCQA recognition program see http://ncqa.org.
What is the Status of PCMHs in Connecticut?
According to the SustiNet PCMH Advisory Committee Report (July 1, 2010), Connecticut has two PCMH initiatives of note—Primary Care Case Management (PCCM) in HUSKY and the state employee plan ProHealth pilot.
PCCM. PCCM was implemented as a pilot program in February 2009 offering a PCMH alternative to HUSKY families in the Waterbury and Windham areas. It was subsequently expanded to the New Haven and Hartford areas. PA 10-166 further expands the program to the Putnam (by July 1, 2010) and Torrington (by October 1, 2010) areas. Providers participating in PCCM are paid on a fee-for-service basis for the medical services they provide (at the Medicaid rate level), but are also compensated $7.50 per member per month for care coordination and other PCMH functions.
State Employee Plan ProHealth Pilot. The state comptroller included a PCMH component in the December 2009 rebidding for the state employee health plan. The comptroller's office, along with Anthem and United Healthcare, plan to partner with ProHealth, a large primary care practice in the state. ProHealth, which serves about 35,000 state employees, plans to transform all 74 of its sites to NCQA -recognized PCMHs by 2011. Other funding partners have agreed to support this through a variety of payment mechanisms including improved fee-for-service rates for some patients, per member per month fees for others, and performance-based incentives.
Does SustiNet Include PCMHs?
The SustiNet legislation (PA 09-148) requires the SustiNet board of directors to establish a medical home advisory committee composed of physicians, nurses, consumer representatives, and other qualified individuals. It must develop recommended internal procedures and proposed regulations for the administration of medical homes serving SustiNet plan members. Among its many responsibilities, the committee was charged with making recommendations on entities that can serve as a medical home as well as on payment for medical home functions. The committee decided to endorse NCQA as the standard for PCMH recognition in the state and also recommended that the state and SustiNet consider recognizing other national PCMH recognition programs as they become available.
The committee's report (issued July 1, 2010) can be found at http://www.ct.gov/sustinet/site/default.asp/
What About Federal Health Care Reform?
The federal health care reform legislation (“Patient Protection and Affordable Care Act” (PPACA; P.L. 111-148) as amended by the “Health Care and Education Reconciliation Act” (HCERA; P.L. 111-152) establishes several demonstration programs and a Medicaid state option to implement and test the medical home model. Following are relevant provisions of the federal law.
State option to provide health homes for enrollees with chronic conditions. The act provides states the option of enrolling Medicaid beneficiaries with chronic conditions into a health home. Health homes would be composed of a team of health professionals and would provide a comprehensive set of medical services, including care coordination (Section 2703).
Pediatric Accountable Care Organization demonstration project. The act establishes a demonstration project that allows qualified pediatric providers to be recognized and receive payments as Accountable Care Organizations (ACO) under Medicaid. The pediatric ACO would be required to meet certain performance guidelines. Pediatric ACOs that met these guidelines and provided services at a lower cost would share in those savings (Section 2706).
Establishment of Center for Medicare and Medicaid Innovation. The act establishes within the Centers for Medicare and Medicaid Services (CMS) a Center for Medicare & Medicaid Innovation. The purpose of the Center will be to research, develop, test, and expand innovative payment and delivery arrangements to improve the quality and reduce the cost of care provided to patients in each program. Dedicated funding is provided to allow for testing of models that require benefits Medicare does not currently cover. Successful models can be expanded nationally. The act also adds payment reform models to the list of projects for the Center to consider, including medical homes (Sections 3021 and 10306).
Training in family medicine, general internal medicine, general pediatrics, and physician assistantship. The act provides grants to (1) develop and operate training programs, (2) provide financial assistance to trainees and faculty, (3) enhance faculty development in primary care and physician assistant programs, and (4) establish, maintain, and improve academic units in primary care. Priority is given to programs that educate students in team-based approaches to care, including the PCMH (Section 5301).
Payments to primary care physicians. The act requires that Medicaid payment rates to primary care physicians for furnishing primary care services be no less than 100% of Medicare payment rates in 2013 and 2014. It provides 100% federal funding for the additional costs to States of meeting this requirement (Section 1202).
What are Some Other Resources Concerning PCMHs?
In addition to the links above, the following provide more information on medical homes:
● “The Medical Home Model of Care,” The National Conference of State Legislatures, July 7, 2010, http://ncsl.org
● “Medical Homes: Will They Improve Primary Care?” Issue Brief, Mathematica Policy Research, Inc., June 2010, No. 6.
● “Federal Health Reform: Patient centered medical Homes,” California Medical Association, June 1, 2010, http://www.cmanet.org/healthreform/applets/fhrs_patient_centered.pdf
● “Initial Lessons from the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home,” The Commonwealth Fund, May 13, 2009, http://www.annfammed.org/cgi/content/full/7/3/254